Antonovsky’s Sense of Coherence

1. Antonovsky’s Sense of Coherence Dana Riley EPI 6181 November 6, 2006

2. Health, Stress & Coping • Description of development of sense of coherence (SOC) • Pathogenesis – focus of health care is reducing consequences of disease • Morbidity hypothesis: at least 1/3 & possibly majority of population is characterized by some morbidity at any point in time • Views health as a continuum ease → dis-ease

3. Salutogenesis • Saluto (health) + genesis (origins) • How do we stay healthy? • Why? • “What are the stressors in the lives of poor people that underlie the brute fact that with regard to everything related to health, illness & patienthood, the poor are screwed?”

4. Tension management • 2 people confronted by same stressor, one meets challenge & other doesn’t • Tension: strain incurred by exposure to stressor • Stress: reserved for the strain that remains when tension is not successfully overcome • Tension management: process of dealing with this tension

5. Generalized Resistance Resources • GRR → {physical, biochemical, artifactual-material, cognitive, emotional, valuative-attitudinal, interpersonal-relational, macrosociocultural} → characteristic of an → {individual, group, subculture, society} → that is effective in → {avoiding, combating} → a wide variety of stressors • When a person regularly experiences the availability of GRRs, a strong SOC develops

6. Sense of coherence (SOC) • Global orientation that expresses the extent to which one has a pervasive, enduring & dynamic feeling of confidence that one’s internal & external environment are predictable • High probability that things will work out as reasonably as can be expected • Generalized, long-lasting way of seeing the world & one’s position in it

7. Sense of coherence (2) • Shaped & tested, reinforced & modified • Constant tendency towards consistency & generalization, stability & continuity • Weak SOC: Anticipate things will go wrong, difficulty expecting needs to be fulfilled, lack hope • Strong SOC: Life is complicated, but understood & in the end things will work out

8. Development of SOC • Certain individuals & social groups likely to have stronger SOC than others • Social-structural & cultural-historical situations provide developmental & reinforcing experiences → strong SOC • Different from internal locus of control (Rotter) – “I am in control” vs. “Things are under control”

9. Operationalizing SOC • Hypothesis: Strong SOC is salutogenic • Operationalize: • Don’t commit to one methodology • Requires exploration before it’s a systematic tool • SOC is not dichotomous • All problems have an answer, challenge/doubt intolerable, no flexibility to adapt to change, claim ultimate control/understanding, denial of sadness, incapacity to admit uncontrollable → Fake SOC

10. Relation of SOC to health • High schizophrenia in lower social classes (Kohn) • Giving-up process antecedent to all disease categories (Engel et al) • Coping ability played an intermediary role between resources & health (Antonovsky) • Social-structural evidence; Animal studies • SOC: Parsimonious way of integrating a great variety of discrete variables

11. So, what has happened since 1979?

12. Unraveling the Mystery of Health (1987) • Continues support of salutogenic approach over pathogenic (e.g., Dirks, Schraa & Robinson, 1982) • Who are the Type A’s that do not get CHD? • Who are the smokers that do not get lung cancer? • Reject health/disease dichotomy • Salutogenic approach compels us to consider the formulation of a theory of coping.

13. 3 components of SOC • Comprehensibility: Extent to which one perceives stimuli as ordered, consistent, etc. • Manageability: Extent to which one perceives resources available as adequate to meet demands. • Meaningfulness: Extent to which one feels life makes sense, some demands worth investing in, challenges welcome.

14. SOC redefined SOC is a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that: • Stimuli derived from environment are structured, predictable, explicable • Resources are available to meet demands • Demand are challenges, worthy of investment & engagement

15. Stressors • Stressor: characteristic that introduces entropy into the system; life experience characterized by inconsistency, under- or overload, & exclusion from decision making • Chronic: Enduring, permanent, generalized phenomenon; primary determinant of SOC • Major life events: Specifiable in time & space; Strength of SOC → outcome is noxious, neutral or salutary • Daily hassles: No automatic adaptive response, but no impact on SOC or health status

16. Measuring the SOC concept • 29-item questionnaire (11 C, 10 MA, 10 ME); 13 item short form • 7-point Likert type scale • Examples: When you talk to people, do you have the feeling that they don’t understand you? Has it happened that people whom you counted on disappointed you? Many people-even those with a strong character-sometimes feel like sad sacks (losers) in certain situations. How often?

17. Antonovsky, A. The structure and properties of the sense of coherence scale. Soc Sci Med. 1993;36(6):725-733. • Internal consistency: Cronbach’s alpha = 0.91 in 8 published, 0.85 in 3 theses, 0.88 in 15 unpublished studies • Face validity: Adequately representative. • Criterion validity: Consistently high correlations with trait anxiety, hardiness & Sheridan’s Global Inventory of Stress • Interesting: 2 studies present low correlations with social support • Factor analysis: Principal components analysis produces one true factor

18. Eriksson, A, Lindstrom, B. Antonovsky’s the sense of coherence scale and the relation with health: A systematic review. J Epi Comm Health. 2006;60:376-381. • Synthesis of findings on SOC & examination of capacity to explain health • Stronger SOC → better perceived health (at least initial ↑SOC) • Relation manifested regardless of age, sex, ethnicity, nationality & study design • Moderating, mediating & main effects on health • SOC seems to be able to predict health • SOC important for health development & maintenance, but doesn’t alone explain overall health • SOC health promoting resource, strengthens resilience & develops +ve subjective state of health